Original article by Douglas G. Smith, MD
Translated into plain language by Helen Osborne of Health Literacy Consulting

image: lower-extremity amputee balancing between chairs Many seniors, aged 65 and over, have diseases which cause disability. Some of these, such as diabetes, obesity, and severe peripheral vascular disease, can result in amputations (limb loss). Here are some facts and figures about amputations (data from the Amputee Coalition and John Hopkins University):

  • More than 1.8 million people in the U.S. have some type of limb loss. This includes arms and legs, but not fingers and toes.
  • More than 185,000 amputations are done each year in this country.
  • About 2% (2 out of 100) of older adults need an amputation.
  • 86,000 amputations each year are due to diabetes. More than half of these amputations are on people aged 50 and over.

The good news for people of all ages – including seniors -- is that there are many new “high-tech” prosthetic devices to help in healing and rehabilitation.

Healing after surgery

After amputation, seniors often need extra time for their wounds to heal. This includes time to get stronger and go through rehabilitation. Healing may take longer for seniors than younger adults. After all, it is harder to heal when you are aged 70, not 17.

Seniors often need extra healing time because they are deconditioned (having lost energy, muscle strength, or motivation). This can occur in the time between getting an infection, ulcer, or gangrene and starting rehabilitation.

Seniors may also have problems with rehabilitation after amputation. This is not only because wounds heal slowly, but also because of medical problems such as heart or lung disease which can decrease a person’s strength and energy. Also, as people age their reflexes get slower, joints become stiff, and muscles are weaker.

Despite all these problems, prosthetic rehabilitation is certainly worthwhile. As a doctor, I try to help every senior with an amputation get back to the highest level of lifestyle possible.

image: woman in hospital with walker being hugged by smiling friendRehabilitation before a prosthesis

The most important rehabilitation goal after a lower limb amputation is learning to transfer safely. People with limb loss say that being able to transfer is the key to being self-sufficient and independent. In fact, most people say that this skill is even more important than walking.

Transfer training should begin the first day after surgery. This is well before the amputation site is healed enough for a prosthesis. People should learn to transfer independently (without help from anyone else). This is needed to get in and out of bed, on and off the toilet, and into and out of the shower or bathtub.

The next rehabilitation goal can be learning how to do activities of daily living (ADLs). This should be done soon after surgery. ADLs include personal hygiene, dressing, eating, and bathroom skills.

After learning how to transfer and do ADLs, a person should then learn new ways to manage and maintain personal space and possessions. This includes arranging possessions in such a way that they can be easily accessed. These skills are needed, whether or not a person gets a prosthesis.

Knee power

Prosthetic rehabilitation is not the same for everyone. One factor is where the amputation is. A person with a “low level” amputation of the foot, ankle, or below the knee still has a knee joint to provide strength and muscle power. A person with a “high level” amputation at or above the knee or in the hip area no longer has knee power.

It makes a big difference to have the power of both knees. Here is a way to test your knee power:

  • Sit in a chair
  • Stand up
  • Sit back down
  • Then raise one foot off the floor and try to lift yourself out of the chair using the other leg

Most people cannot pass this test without using their arms to push themselves up. And once standing, people have to put all their weight on one leg which greatly affects balance.

The knee is very strong and needed for walking, rising, sitting, lifting, and transfers. Hip muscles, which can move the residual limb forward and back, do not provide the strength of a knee.

Prosthetic knees, even the ones with high-tech microprocessors, cannot replace knee power. While I am hopeful about the new knee units being tested, there is no prosthetic knee yet that can help a person get from standing to sitting like a real knee.

Amputations below the knee

A person with an amputation below the knee (such as partial foot, ankle level, and transtibial amputations) may start prosthetic training soon after surgery. He or she may find it helpful to use a prosthesis for transfers, balance, and going from sitting to standing.

Amputations at, or above, the knee

The higher an amputation, the harder it can be to learn how to use a prosthesis and walk. This is mainly because of the loss of knee power. Before a person with a high-level amputation is fitted with a prosthesis, he or she should be able to:

  • Transfer in and out of bed, independently
  • Go from sitting to standing, independently
  • Walk in parallel bars or with a walker for at least 25 feet

One of my patients whose below-knee (transtibial) amputation was revised to an above-knee (transfemoral) amputation said, “Doc, you told me this transfemoral rehab would be 10 times harder than it was for my transtibial amputation. It’s more like 100 times harder!”

High-tech prosthetic devices

New high-tech prosthetic devices can help people of all ages. While first used by young and active people, today’s high-tech prostheses also help older adults who struggle to stand and walk.

New technology includes knee units, shock-absorbing pylons, and other components. These help reduce stress to the body, increase stability, and lower the chance that a person will fall because a prosthesis buckled.

Many seniors with limb loss tell me that they feel confident using high-tech devices. They say that there is less jolting and jarring to their hips and back. They also say that microprocessor knees help protect them from stumbling and falling.

New technology also helps increase a person’s “mental energy.” This is when walking becomes automatic (without a lot of thought) when technology matches their physical needs. But even with technology, a person with a high-level amputation must think more about walking, especially on uneven surfaces or unfamiliar terrain. Things to think about include:

  • How slippery is the ground?
  • How steep is that hill?
  • Is that dirt very loose, or will it provide good traction?
  • Will my technology allow me to adjust and adapt when the person walking in front of me stops suddenly or cuts across my path?

Older patients and newer technology

While many older patients say that new technology helps with stability, stumbling, concentration and mental energy, there are few studies which prove these benefits. Without studies, insurance companies may question the value of paying for high-tech prosthetic devices.

To me, new technology is of great benefit to older users – not just those who want to run faster. It can benefit older adults who simply want to move around safely and comfortably. High-tech prostheses can help people do their own shopping, cleaning, and cooking. I also believe that this technology is cost-effective, as it can help an older adult be more independent. Certainly, this costs less than paying for many years of assisted living.

My hope is that all people with limb loss get prosthetic devices that best match their needs. I hope that we do not make the mistake of using new technology just for people who are young and strong. New technology can help seniors in many ways -- it lets them return to the activity level they enjoyed before amputation, lowers the chance a person will stumble and fall, and increases a senior’s confidence to enjoy life again.

“To know how to grow old is the masterwork of wisdom and one of the most difficult chapters in the great art of living.” Henri Frederic Amiel, 19th century Swiss philosopher and poet.

“The oldest trees often bear the sweetest fruit.” – German proverb

I certainly agree with the philosopher Francis Bacon, Sr., who said, “Old wood best to burn, old wine to drink, old friends to trust and old authors to read.”

Last updated: 08/18/2014
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